Allen,
Let me see if I've got this arrangement straight ...
Lawmakers want reports on performance and services. [Lawmakers also
appropriate dollars for use by Government Program, which in turn uses
them to fund Local Agencies under contract?]
-- Seems to be a sponsor - payer relationship.
Government Program reports performance and services to Lawmakers based
on information received from Local Agencies. Government Program funds
Local Agencies to provide Services via contract.
-- Seems to be a payer - sponsor relationship in one direction
and a payer - provider relationship in the other.
Local Agencies provide healthcare services and report performance
information to Government Program.
-- Seems to be a provider - payer relationship.
Assuming I've summarized this correctly, the answer to your question
is actually the answer to some other questions.
Does Government Program meet any of the HIPAA definitions of a
"health plan"?
Is payment from the Government Program to a Local Agency based on
each service provided? {45 CFR 162.1101 (a)}
Does the Government Program reimburse a Local Agency in some way
based on the service and performance (i.e., "encounter") information
it receives?? {45 CFR 162.1101 (b)}
Are the Local Agencies contracted and funded based on some
mechanism that is not related to reporting of the healthcare services
provided and/or performance (i.e., not "reimbursed")?
The answers to the questions above will determine the answer to your
question below. Good luck and give your attorneys my best. :-)
Dave Feinberg
Rensis Corporation [A Consulting Company]
206-617-1717
[EMAIL PROTECTED]
----- Original Message -----
From: "McCall, Allen" <[EMAIL PROTECTED]>
Sent: Thursday, January 24, 2002 8:16 AM
Subject: RE: DDE and the Use of Utilization Review Protocols for 278
Transacti ons
Would your response also apply to this situation:
A government program that provides mental health care contracts with
local
agencies (also government) to provide the services. The government
program is required to report the lawmakers its performance and to
track services. The program currently collects data from the local
agencies that is not included in a 837 encounter in order to meet its
reporting requirements.
Can it continue to collect the data in non-standard transactions?
Allen
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